Background: Advancing orthopedic care through large language models requires both multimodal processing capabilities for medical images and open-source deployment options for secure in-house operations, yet these remain underexplored in current literature. This study aims to benchmark open-source vision-language models (VLMs) against orthopedic residents using the Orthopedic In-Training Examination (OITE), assess domain-specific performance across orthopedic subspecialties, and investigate the relationship between model parameter size and performance. Methods: Six open-source VLMs of varying sizes (Alibaba Qwen2.5-VL-72B-Instruct, Alibaba Qwen2.5-VL-32B-Instruct, Alibaba Qwen2.5-VL-7B-Instruct, Alibaba Qwen2.5-VL-3B-Instruct, Meta Llama-3.2-90B-Vision-Instruct, Meta Llama-3.2-11B-Vision-Instruct) were evaluated using the 2023 OITE (210 questions; 111 with images). Model performance was compared to resident scores from the 2023 OITE technical report. Pearson correlation coefficient was used to assess the association between model size and performance. Results: The 2 largest open-source models, Qwen2.5-VL-72B and Llama-3.2-90B, demonstrated performance levels comparable to those of second-year orthopedic residents on the OITE examination. A mid-sized model, Qwen-32B, slightly outscored first-year residents. In contrast, small-sized models (under 11 billion parameters) performed worse than first-year residents. Qwen2.5-VL-72B performed best in foot & ankle and sports medicine topics, while Llama-3.2-90B was strongest in basic science and hand & wrist.All models had the most difficulty with spine and pediatric questions. Overall, model accuracy increased steadily with model size up to 72 billion parameters, but larger sizes showed little additional improvement. Conclusions Smaller models offer reduced accuracy in exchange for lower hardware requirements. Spine and pediatric domains remain consistently areas of underperformance across all models. Model selection should be based on domain-specific benchmark results to balance clinical needs with hardware limitations. While promising, open-source VLMs currently require further refinement and validation before they can be reliably applied in clinical or educational settings.

Purpose: This study evaluated the nutrient content of nutrition bars sold in Korea. Methods: Three hundred and twenty-five products were collected from online marketplaces and classified according to the bar type, food category, and protein source. The nutritional content per serving was analyzed using the percent daily value (% DV) and the index of nutritional quality (INQ). Results: The nutrition bars provided 9.6% DV for energy, 6.7% DV for carbohydrates, 16.8% DV for protein, and 16.9% DV for fat. Fat contributed 42.5% of the total energy, exceeding the recommended range (15–30%). Fat and saturated fat showed high INQs (1.8–1.9), whereas sugars, sodium, and cholesterol had much lower values (0.1–0.7). Chocolate bars had the lowest protein but the highest energy, sugars, fat, and saturated fat, with saturated fat alone contributing approximately 50% DV (INQ 3.6). Energy bars showed significantly high fat-derived energy proportions (52.9%) and INQ values for total fat and saturated fat (1.7–2.2), even though their total energy content was not particularly high. Cereal bars exhibited generally low nutrient levels, except for fat INQ (2.0). Protein bars delivered the highest protein (26.1% DV, INQ 3.0) but the lowest sugars (5.5% DV, INQ 0.6). Among the protein bars, chocolate-based products were high in energy and carbohydrates. Protein bars formulated with mixed protein sources (70.4%), primarily soy and milk (60.4%), contained the highest protein (28.4% DV, INQ 3.3) compared to the products with only plant- or animalbased proteins. Among the optional nutrients, dietary fiber (36.6%) and allulose (19.4%) were the most commonly labeled, mainly in protein bars. The fiber content averaged 32.5% DV (INQ 2.6), with energy and cereal bars approaching 50% DV. Conclusion Nutrition bars may contribute to the daily nutrient intake but require a careful choice due to the compositional differences according to types and formulations.

Background: Previous literatures suggest that the prognosis of Kienböck’s disease might be favorable despite no surgery if it is diagnosed in late age, but the evidence is not clear. The aim of this study was to determine the radiographic and clinical progression of Kienböck’s disease diagnosed at more than 50 years of age. Methods: Data of 27 patients diagnosed with Kienböck’s disease at more than 50 years of age between 2000 and 2016 were investigated. During the study period, no treatment, either surgical or nonsurgical, was applied. We explained to the patients that the affected lunate was not expected to collapse further if found late in age. Annual visits were recommended, through which radiographic and clinical observation was made. We assessed changes in Stahl index and radioscaphoid angle between the initial assessment and the final follow-up, and clinical assessment was made using pain in visual analog scale (VAS) and Dornan’s criteria. Results: Initially, 2 patients were in Lichtman stage 1, 6 in stage 2, 5 in stage 3A, 11 in stage 3B, and 3 in stage 4. Radiographic follow-up of at least 5 years (mean, 7.8 years) was made in 14 patients, whose Stahl index and radioscaphoid angle did not differ significantly from their initial measurements. Arthritic appearance was not found, and progression in the Lichtman stage was detected in 1 lunate, from 3A to 3B. Despite no surgical treatment for an average of 7.5 years (range, 5.0–15.7 years) of observation period in the 27 patients, average pain in VAS improved from 3.5 (range, 1–7) to 0.8 (range, 0–2), with excellent or good clinical status by Dornan’s criteria. Conclusions Our study suggests that Kienböck’s disease diagnosed at more than 50 years of age can follow a benign natural course in radiographic and clinical aspects. Therefore, surgical interventions should be considered carefully in this age group.

PURPOSE: Pediatric intra-articularproximal phalangeal head fractures of the big toe are very rare and few studies on this have been published. The purpose of this study is to present the diagnostic approach and surgical management of these extremely rare fractures, which might be easily underestimated or misdiagnosed.MATERIALS AND METHODS: The study retrospectively reviewed all the patients who were diagnosed as intra-articular proximal phalangeal head fracture of the big toe and who underwent surgical intervention in our institution. The size of the bony fragment and hallux valgus interphalangeus angle were measured on the preoperative X-rays. The size and rotation of the osteochondral fragment, the presence of avascular necrosis, ligamentous injury and soft tissue entrapment were assessed on the preoperative magnetic resonance images (MRIs). The radiologic and functional evaluation were performed at 1 year postoperatively.RESULTS: The average size of the bony fragments measured on the X-rays was 4.1 mm in width and 2.3 mm in length. Two cases showed hallux valgus interphalangeus. Preoperative MRI was performed in four cases and the average size of any osteochondral lesion was 5.3 mm in width, 3.9 mm in length, and 4.7 mm in height. Rotation of the osteochondral fragment was observed in one patient, and soft tissue entrapment was noted in two patients. Postoperatively, successful bony union was achieved in all the patients and the average time to union was 74.4 days.CONCLUSION: Intra-articular proximal phalangeal head fractures of the big toe are very rare and often neglected due to incomplete ossification in the pediatric population. It is important to suspect the presence of this intra-articular fracture and to appropriately implement further evaluation. Nonunion of chronic cases as well as acute fractures can be successfully treated through open reduction and internal fixation using multiple K-wires.
Hallux Valgus ; Hallux ; Head ; Humans ; Intra-Articular Fractures ; Ligaments ; Magnetic Resonance Imaging ; Necrosis ; Retrospective Studies

Distal radius fractures (DRFs) are one of the most common fractures seen in elderly people. Patients with DRFs have a high incidence of osteoporosis and an increased risk of subsequent fractures, subtle early physical performance changes, and a high prevalence of sarcopenia. Since DRFs typically occur earlier than vertebral or hip fractures, they reflect early changes of the bone and muscle frailty and provide physicians with an opportunity to prevent progression of frailty and secondary fractures. In this review, we will discuss the concept of DRFs as a medical condition that is at the start of the fragility fracture cascade, recent advances in the diagnosis of bone fragility including emerging importance of cortical porosity, fracture healing with osteoporosis medications, and recent progress in research on sarcopenia in patients with DRFs.

PURPOSE: The purpose of this study was to suggest a multimodal diagnostic approach to determine the cause of the disease in patients diagnosed with synovitis of the wrist and who underwent synovectomy. MATERIALS AND METHODS: Twenty-nine patients, who underwent contrast magnetic resonance imaging (MRI) preoperatively and synovectomy from January 2000 to December 2013, were reviewed retrospectively. Among them, 17 patients underwent a Tc99m white blood cell (WBC) scan preoperatively. In patients who met the diagnostic criteria of rheumatoid arthritis (RA), the diagnosis was confirmed as RA if the MRI finding or histology was compatible with RA. If the MRI finding and histology were disparate, the final diagnosis was made based on the histologic finding. RESULTS: Of the nine patients who met the diagnostic criteria of RA, seven patients were finally diagnosed as RA and two patients as tuberculous arthritis. Of the 20 patients who did not meet the diagnostic criteria of RA, the MRI findings and histology were consistent with the same disease in 12 patients. In the remaining eight patients, five were diagnosed with nonspecific chronic synovitis, one with RA, and two with tuberculous arthritis based on the clinical findings, MRI, and histology findings. CONCLUSION: MRI and a WBC scan are very useful imaging modalities for diagnosing the causative condition of the wrist synovitis. A histology evaluation after synovectomy can also be useful in cases with a difficult diagnosis or are refractory to medications.
Arthritis ; Arthritis, Rheumatoid ; Diagnosis ; Humans ; Leukocytes ; Magnetic Resonance Imaging ; Retrospective Studies ; Synovitis* ; Wrist*